Thursday, January 23, 2014

Conservatives could muster a clear-thinking critique of Obamacare if they wished, and maybe even put forward a genuine alternative. Unfortunately, though, many of the conservative attacks on Obamacare don’t make much sense, when evaluated against conservative’s own heretofore views, not against liberal concepts of good policy.

1. Conservatives used to be for high deductible plans, until they were against them, when it comes to Obamacare, that is. Bloomberg News points out that Republicans in the early 1990s advocated for high deductible plans as an alternative to the more generous benefits proposed by President Clinton:

“As Democrats pushed for universal health care during the Clinton years, Republicans argued that consumers should pay a greater share of their medical bills. In 1996 the GOP-controlled Congress passed legislation allowing some people to pair high-deductible plans—which barely existed—with tax-free health savings accounts. That meant that small business owners and their employees, as well as others with limited insurance options, could put away pretax earnings to pay for routine care and buy cheap insurance to cover catastrophes. In 2003 Congress, still under GOP control, passed legislation making health accounts more widely available.”

Today, Republicans are in a lather about Obamacare’s high deductible plans, exposing what policy wonk Ezra Klein deems “their hypocrisy” over Obamacare (his words, not mine—I think inconsistency is a fairer description). Aaron Carroll, a professor of pediatrics at the Indiana School of Medicine, opines in Bloomberg that conservatives newfound dislike of high deductible plans brings them to the right (correct) position:

“The revelation that many plans in the Patient Protection and Affordable Care Act’s health insurance exchanges have high deductibles, has put many of the law’s conservative opponents into a corner: Once in favor of high deductibles, these critics of Obamacare are suddenly worried about the risk to consumers. The data show why their new position makes more sense.”

2. Conservatives used to be in favor of moving people out of employer-based coverage but now bemoan every employer who drops coverage because of Obamacare. Typical is an anti-Obamacare screed from the Republican Senate Policy Committee, warning that people “relying on employers to cover employees’ spouses on the company health plan may find the health care law isn’t ‘working fine’ for them. The law’s mandates and fees are driving up health care costs and making it harder for employers to continue offering health insurance to workers’ families. Some employers have even stopped offering spousal coverage altogether.” Avik Roy, a conservative physician commentator and former Romney advisor, has predicted that Obamacare will result in employers “cancelling” policies for 80 million employees (which, by the way, has been disproven by independent fact-checkers—his estimate is way too high, and the policies aren’t actually being cancelled, just changed to meet Obamacare’s requirements, such as the requirement that young adults be eligible for coverage under their parents’ plans).

But even if it were true that some employers eventually will decide no longer to provide health insurance in favor of allowing their employees to buy individual (and subsidized coverage) from the competing health plan offered through Obamacare’s exchanges, delinking health insurance from employment used to be what conservatives favored (and some still do). For example, the libertarian Cato Institute supports elimination of the tax deductibility for employer-sponsored insurance—a far more radical and disruptive approach to ending employer-based insurance than any drop in employer-based coverage from Obamacare:

“In any case, with the removal of the subsidy for health care above catastrophic coverage, the incentive to obtain so much insurance would diminish. Thus, many people would reduce coverage to that level. Insurance companies could help individuals with catastrophic risk management—their traditional function. Firms could get out of the business of managing, rationing, and buying health care. We would delink insurance from employment, ending the portability problem and dramatically reducing the brouhaha over pre-existing conditions. Individuals would have better incentives and more control. More broadly, we need to move away from third-party payment and toward two-party transactions in health care.”

3. Conservatives invented the idea that individuals should be required to buy health insurance but now vociferously oppose Obamacare’s individual mandate. Forbes magazine recounts conservatives’ “torturous” shift on the individual mandate, from originally favoring it as a market-based, personal responsibility alternative to compulsory government-mandated coverage (single payer) or employer-mandated coverage, to now decrying it as socialism:

“. . . Some conservatives, seeking a more market-oriented path to universal coverage, began endorsing an individual mandate over an employer mandate. An individual mandate would address the ‘free rider’ problem caused by EMTALA, by requiring people to buy their own insurance. In addition, moving to a more individual-based system from the employer-based one would significantly increase the efficiency of the health-insurance market.

With these considerations in mind, in 1989, Stuart Butler of the Heritage Foundation proposed a plan he called ‘Assuring Affordable Health Care for All Americans.’ Stuart’s plan included a provision to ‘mandate all households to obtain adequate insurance,’ which he framed explicitly as a way to address the ‘free rider’ problem and employer mandates.”

To be fair, there is plenty of inconsistency among liberals, and people often change their minds, for good or at least justifiable reasons in their own minds. But the fact is that until Obamacare, the conservative alternative to government-run health insurance was to provide tax incentives for people to enroll in high deductible plans, to delink coverage from employment, and to require that people to buy coverage. Yet they oppose these elements when associated with Obamacare.

This is a problem, because this country needs to have a spirited debate about today’s conservative alternative to Obamacare, one that would limit government and promote free markets yet still expand access to millions of uninsured. But conservatives need to first figure out what they are for, not just what they are against, which apparently is anything having to do with Obamacare, even if similar to the things they used to be for. Do they still favor high deductible plans? Do they still want to delink coverage from employment? If they no longer support an individual insurance mandate, what alternative do they have in mind to make sure that risk is spread among the young and healthy and the old and sick? We need to know.

Finally, before readers of this blog accuse me of only going after the conservative response to Obamacare, stay tuned. My next post will be about liberals’ blind-eyes to the unintended adverse consequences of Obamacare.

Today’s questions: Do you agree that conservative critiques of Obamacare are confusing and inconsistent with their past views? And if so, is this a good or bad thing?

Wednesday, January 15, 2014

Well, I’m back--with my first ACP Advocate blog of the year! After a very restful couple of weeks with my family, including a trip to beautiful (and warm) Key West over the holidays, I came back to the bitter cold (polar vortex, I’m told) gripping Washington, D.C. and most of the rest of the country. Then, just a little over a week into 2014, my new year started off with a bang--literally--as I got into an automobile accident that involved my car sideswiping another vehicle and then crashing my car into a tree at 30 MPH. The car was totaled, but fortunately, I (mostly) walked away from the accident with only a fractured sternum and bruising. Today, just a little over a week from the accident, I’m doing fine--back at work, only modest discomfort. I bring up my accident because it taught me some valuable lessons, which I think are applicable to the ongoing debate over the Affordable Care Act. As I blogged in the Philadelphia Inquirer last week, government regulation probably protected me from sustaining a much greater injury from my accident. I encourage you to read the entire post, but let me summarize the salient points: 1. We all are invincible, until we aren’t. Accidents and illnesses can happen at a moment’s notice, whether you are a 57 year old like me, who always assumed serious auto accidents are something that happens to someone else because of my heretofore spotless driving record, or whether you are a 27 year old “young invincible.” When you get sick and hurt, you will need good health insurance, which I was fortunate to have through my employer, the American College of Physicians, but millions do not. Opting out of insurance coverage, at any age, is just plain dumb. 2. We may not like it when the government infringes on our personal liberties by requiring us to buy products we think we don’t need, sets consumer safety standards for the products we buy that add to their cost, or requires or forbids us from doing certain things that can endanger us—but such mandates sometimes are necessary to protect us from greater harm. In my case, federal requirements that cars have seat belts, airbags, and front end collision protection likely protected me from far more serious injury, even death. Such mandates added hundreds, maybe thousands of dollars, to the purchase price of my car, but they were worth every penny when my health and safety depended on them. (If I had driven a “grandfathered,” older car that lacked air bags and other federally-mandated crash protections, I may not be here writing this blog today). My local government required that I buy auto insurance, another unfunded mandate on me. It required me to wear a seat belt and shoulder restraint system, another mandate to prevent me from doing something really stupid, driving without a seat belt. Sure, even without such mandates, I would have worn a seat belt and bought auto coverage on my own, but this unfortunately is not true of everyone on the road. 3. So it is with Obamacare: the government requires us to buy health insurance, because having good health insurance is essential when you get sick or hurt. The government mandates that the health insurance that is sold to us meets consumer protection and benefit standards, like no pre-existing condition exclusions and coverage of essential benefits, so that the coverage actually helps us when we really need it—even if it means we have to pay more for it. Just like the government requires that the new cars we buy have safety features we may think we will never need or use, like airbags, until we do and are glad we have them. 4. I am fortunate that I already had good health insurance coverage through my employer, but there are millions of uninsured persons that have had no access to health insurance, or only had access to inadequate plans sold on the individual insurance market—until Obamcare came along to set standards for the insurance industry and provide financial help so people could afford it. Contrast my experience last week with those who do not have good health insurance. Here is how I put it in the Philadelphia Inquirer blog: “Now, let’s think about what might have been the outcome for someone in the same circumstances as me, but without health insurance and with a much more modest income. Because this person didn’t have health insurance, he might have decided not to go to the ER, he might not have gotten the prescriptions filled because of the cost, making his recovery much more painful (believe me!). The hospital ER might have written off some of his costs by cost-shifting to people with insurance, but he still might have left with a huge bill. He might have missed more days of work without pay. And if his car didn’t have airbags and he wasn’t wearing a seatbelt, he could have suffered a catastrophic life-threatening injury. Now, consider the tens of millions of people who find themselves in the same circumstances but who lacked good coverage before Obamacare. They will now be required to buy and will get government help in purchasing health insurance that by law must include essential benefits. Their new coverage will also meet various consumer protection standards, like a ban on discriminating against people with pre-existing conditions and on lifetime and annual limits on coverage. The consumer protections in their new coverage will protect them from going bankrupt if they need healthcare. These safeguards may even be what keeps them alive. Many of them may not think they need this protection—until they do.” Now, I know that some readers of this blog will argue that it is “paternalistic” for the government to require that we buy health insurance that has benefits that we think we don’t need or want. I have argued that setting standards for health insurance companies isn’t really paternalistic, while my friend Dr. Bob Centor argues in his DB’s Medical Rants blog that it is. I will concede his point—government mandates that limit our personal choices or regulate the products we buy are paternalistic, to a point. But when I drove my car into a tree last week, it was government paternalism that likely protected me from greater harm, just like Obamacare’s paternalism protects us by requiring that everyone have health insurance that meets federal consumer protection standards, so that when we get sick or hurt (as we all will at some point), we have health insurance that helps keep us medically and financially sound. Today’s question: Do you agree with the lessons I drew from my accident on government’s role in mandating standards that can help keep us safe and sound, even if it limits our personal choices to some degree?